BLOGGERS: MARK SCHOLZ, MD & RALPH H. BLUM

Tuesday, February 26, 2013

BY MARK SCHOLZ, MDMy life is turning into an evangelistic crusade to raise awareness about the risks of prostate cancer treatment. Tens of thousands of men are undergoing unnecessary radical prostate cancer therapy with dire sexual consequences. These inappropriate and often fatefully wrong treatment choices are made because men are often completely unaware of the irreversible effects of the treatment itself.Thankfully, I am not alone in this battle to inform men about the harm associated with prostate surgery. Another prostate oncologist, Dr. Celestia Higano from the University of Washington, recently published a scientific review on this very topic in the Journal of Clinical Oncology (JCO). For those of you who haven’t heard of the JCO, I consider it to be the most prestigious scientific cancer journal in the world.Today’s blog will offer quote seven selected sections from Dr. Higano’s important article. To add some gravitas to the eye opening statements you are about to read, please realize that every one of her comments was referenced to a specific scientific report. In other words, these statements have nothing to do with opinions. They are genuine outcomes from published scientific studies.So without further ado let’s start with the first quote from the article:

Quote #1: “Unfortunately, many couples believe that even if they have problems with erectile dysfunction (ED) … they will be able to resume their normal sexual practices through the advances of modern technology.4 They are not informed that sexual function will never be the same after any form of therapy and they are often unprepared for the changes in their sexual and intimate relationship.” (Italics mine)

Quote #2: “PDE5 inhibitors (Viagra, Cialis) and other erectile aids are not successful for all patients with ED and, even when effective, half the patients stop using them within one year.11 Why couples stop using ED therapies has not been adequately investigated , but disappointment that sex life is not the same … likely contributes to this outcome.”

Quote #3: “In a Memorial Sloan-Kettering series of 475 men … 20% of men who had radical prostatectomy (RP) had climacturia at one year, and climactauria as associated with both painful orgasm and penile shortening.13” (Climacturia means that orgasm results in the ejaculation of urine instead of semen).

Quote #4: “At the Karolinska Institute, 1,288 patients had either open or robotic-assisted laparoscopic RP, and of the 691 men who were sexually active, 38% reported climacturia at least sometime during sexual activity. Of the men who reported climacturia, 72% had climacturia less than half the time, 17% more than half the time, and 11% all the time.14”

Quote #5: “In a review of 1,459 men who had RP at New York University, climacturia was found to decrease from 44% at 3 months to 22% at 24 months after surgery. Climacturia is a common complication of RP but is often overshadowed by concerns about ED and overt urinary incontinence.14-16”

Quote #6: “In a study of VED (vacuum erectile device) use after RP, the length and circumference of the penis decreased in 63% of patients who did not use a VED after RP compared with only 23% who did.18-20”

Quote #7: “Surgery can also result in Peyronie’s disease (also called, “crooked penis”) in up to 16% of patients.23"

When patient are informed of the dire consequences of surgery they are often mystified as to why urologists, who must be aware of the damage surgery causes, continue vigorously to recommend it. I have heard many patients voice the opinion that urologists are driven by a selfish desire for financial gain. The financial motive, however, fails to ring true. As medical procedures go, prostate surgery is poorly reimbursed. Also, when urologists are diagnosed with prostate cancer they themselves often proceed with a radical prostatectomy. So money is not the primary issue. Rather, consider that performing surgery is part of the very fabric of a surgeons’ persona. From a surgeon’s point of view, if you are not operating, you are not a surgeon.Men considering surgery for prostate cancer need to be aware of its substantial risks. And when getting advice about which treatment to select, patients also need to realize that surgeons usually can’t provide balanced advice. They are too close to the trees to see the forest.

Wednesday, February 20, 2013

If you have
just been diagnosed with prostate cancer you are not alone. The American Cancer
Society estimated that there would be over 241,000 new cases in the U.S. in
2012. And those men probably received a ton of information and advice from
multiple sources to help them choose the best treatment.

Obviously their choice had to be guided by the clinical stage of their cancer,
the extent of the disease, and their age and overall health. Undoubtedly they
asked dozens of questions before making a final treatment decision. But a
question seldom asked is: “What are the psychological implications of the
treatment?”

My prostate cancer journey began in 1990, and I monitored the cancer for 12
years before my PSA bumped up to a point that made some form of treatment
necessary. I chose hormone blockade, because being deprived of
testosterone seemed more appealing than having my prostate sliced out or fried
by electrons. However, I discovered that
every cancer treatment comes with a stiff price—both physically and psychologically. So what is the best
way to help combat the fear and stress of dealing with prostate cancer?

For me, the great “home remedy,” the ultimate anti-oxidant, is laughter. And
that is not some demented form of denial. Over the past ten years, I have found
that of all the things people have recommended to help get me through the bad
times, laughter is at the top of the list.

“The best doctors in the world are Doctor Diet, Doctor Quiet and Doctor
Merryman.” So wrote Jonathan Swift (1667-1743). Norman Cousins emphasized
the healing power of laughter in his book, Anatomy
of an Illness.Cousins called
laughter “internal jogging.” And in his book, Peace, Love & Healing, Bernie Siegel wrote that, “love,
laughter and peace of mind are physiologic.”

Without a doubt, laughter is the ultimate antioxidant. Here’s how the Discovery
Health Web site describes the impact of laughter on the immune system: “When we
laugh, natural killer cells which destroy tumors and viruses increase, along
with Gamma-interferon (a disease-fighting protein), T cells (important for our
immune system) and B cells (which make disease-fighting antibodies. As well as
lowering blood pressure, laughter increases oxygen in the blood, which also
encourages healing.”

Believe me when I say that my somewhat warped sense of humor has been a
blessing to me in devastating moments. Time and again I have seen the relief
and release that even stupid jokes or bawdy humor can provide to men who are
under the gun. Cousins claimed he laughed his way back to health with old
Groucho movies. For me, it was the amazing Carol Burnett, with the Marx
Brothers a close second.

So find what works for
you, because studies have shown that the debilitating emotion of fear can’t
coexist with laughter, and that the relaxation response following a good laugh
is worth its weight in gold. The message is clear: Lighten up!

Tuesday, February 12, 2013

As
Executive Director for the Prostate Cancer Research Institute, I am often asked
about our research focus. The PCRI has given unrestricted grants to various
institutions over the years. These institutions are listed on the website at www.PCRI.org.In addition, since the inception of the
PCRI, Dr. Lam, Dr. Strum and I have published at least ten scientific articles
relevant to prostate cancer in peer-reviewed journals This blog very briefly
summarizes the most useful conclusions that can be drawn from this body of work
(the article titles are in italics).

1. Anemia associated with androgen deprivation
in patients with prostate cancer receiving combined hormone blockade:We were the first to report that blocking
testosterone can result in anemia, i.e. a drop in red blood cell (RBC) counts.
The anemia caused by low testosterone resolves spontaneously when testosterone levels
are restored to the normal range. Doctors need to be aware of the cause of this
phenomenon or else men are unnecessarily subjected to treatment with iron
(which may stimulate prostate cancer growth) or to uncomfortable diagnostic
studies such as bone marrow biopsy.

2. Low-Dose Weekly Docetaxel (Taxotere) in
Elderly Men with Prostate Cancer:Rather than giving a standard dose of Taxotere every three weeks, which
can be associated with low white blood cell counts, infection and excess
fatigue, we evaluated 20 elderly men (average age 78) with a 1/3 dose of
Taxotere administered weekly.We found
the anticancer effect to be maintained (twelve of the twenty men in the study
had more than a 50% decline in PSA).However, side effects were reduced: Only three of the patients stopped
treatment for reasons of fatigue.No
patients experienced low blood counts or infections.

3. Using Splines* to Detect Changes in PSA
Doubling Times: We collaborated with two mathematicians from UCLA, Robert
Jennrich and Ray Redheffer, to develop a mathematical model for measuring the
change in the rate of PSA rise after starting a new therapy.

4. Modified Citrus Pectin (MCP) Increases the Prostate-Specific
Antigen Doubling Time in Men with Prostate Cancer: A Phase II Pilot Study:This study used the statistical methods
developed in the previous study to measure PSA doubling times before and after
starting MCP. We showed a significant slowing in the rate of PSA rise in seven
of the ten men who were administered MCP in the study.

5. Long-Term Outcome for Men with Androgen
Independent Prostate Cancer Treated with Ketoconazole and Hydrocortisone:
Ketoconazole was the best treatment for men resistant to Casodex and Lupron before
FDA approval of Zytiga and Xtandi. In 2005 we published a report of 78 patients
showing PSA suppression for an average of 14.5 months.Even longer responses occurred when treatment
was initiated when men were in the earlier stages of androgen independence.

6. Intermittent Use of Testosterone
Inactivating Pharmaceuticals (TIP) Using Finasteride Prolongs the Time Off
Period: This study of 101 men treated with intermittent TIP reported a
number of interesting findings: The “Holiday Period” after TIP is stopped is doubled
[twice as prolonged] when finasteride (Proscar) is employed. Longer holiday
periods were also associated with advanced age and lower Gleason score.

8. Prostate Cancer-Specific Survival and
Clinical Progression-Free Survival in Men with Prostate Cancer Treated
Intermittently with Testosterone Inactivating Pharmaceuticals: 160 men were
treated with TIP and monitored for survival over 10 years. We found that the
single most powerful factor for predicting extended survival was to have
attained a PSA less than 0.05 within eight months of starting TIP.

9. Primary Intermittent Androgen Deprivation as
Initial Therapy for Men with Newly Diagnosed Prostate Cancer: This study
was an observational report on 73 men who were eligible to have surgery or
radiation but instead elected to initiate TIP. After an average observation
period of 12 years, three men died of prostate cancer. Of the remaining 70 men,
none developed metastasis. 28 men underwent delayed surgery or radiation. On
average, the delayed surgery or radiation occurred 5.5 years after TIP was
first initiated.

10.
Primary Androgen Deprivation (AD)
Followed by Active Surveillance (AS) for Newly Diagnosed Prostate Cancer (PC):
A Retrospective Study:This study
evaluated 102 men treated with initial TIP to determine how often a single
course of TIP for 12 months resulted in durable remission (defined as more than
7 years).Durable remission occurred in
94% of men in the Low-Risk category,
47% of men with Intermediate-Risk prostate
cancer and only 29% of men with High-Risk
disease. There were no prostate cancer deaths.

Conclusion

One
consistent theme in our published research is that stand-alone hormonal therapy
is a reasonable option for men with Intermediate-Risk
category prostate cancer. Men with Low-Risk
disease are best managed with initial observation, i.e., without any initial
therapy at all.Men with High-Risk diseaseshould be treated with a combination of TIP plus radiation.

Another
important conclusion is that while the side effects of TIP can be managed, they
tend to be more notable than the side effects of other popular treatments for Intermediate-Risk prostate cancer such
as radioactive seed implants or intensity modulated radiation therapy (IMRT).
The main exception being a somewhat lower risk of permanent erectile
dysfunction with TIP compared to radiation.

Lastly,
the overriding theme of all modern prostate cancer research is that
over-enthusiasm for curative treatments that extend life must be tempered by
the potential negative impact that treatment can have on quality of life.

* A
“spline” is a bent line, i.e. a line with an angle. When rising PSA levels are
represented graphically the dots can be connected creating a line.If there is a change in the rate of rise, an
angle in the line occurs.

Tuesday, February 5, 2013

I’m interrupting my series of Blogs on “Stress” to give you a bulletin from the front. It concerns my latest PSA. It caught me off guard and gave me a bad moment.

I talk about these nervous-making moments often enough with men who contact me after reading “Snatchers.” But that’s them. This is me, my prostate. And there it is: the sinking feeling in the gut, half-panic, half “Oh s--t!” Not that this toxic cocktail is new to me. But it is never quite something that even my long experience with prostate cancer never lets me to take in my stride.

I have been away on vacation. Just got back. Did anyone discuss your elevated PSA with you? It was elevated to 26. Can you give me a call today?

Mark

I realized I had stopped breathing. No, no one has discussed my elevated PSA with me. 26! Ouch! In less than three months—for no reason I can think of—that’s up by more than 40%!

Dialing Mark, I thought what my friend, Harvey, would say: “Well, my PSA is 60—and I don’t even have a prostate! Consider yourself blessed. . . . You’re going to die in your sleep in 20 years after dinner out and a good movie.”

Yeah, well, I still feel like I’ve eaten rotten fish.

Mark doesn’t sound concerned. He wants to know if I’ve noticed any symptoms of an enlarged prostate. No. Done any heavy lifting? Negative. “Well, let’s put you on an antibiotic for ten days—you tolerate Cipro alright—and then have you see Duke Bahn_for a Doppler MRI. He’s taking Medicare again. Then in about three weeks we’ll do a repeat PSA.”

Makes sense. But the panic is still there; the fear that perhaps I have tempted fate one too many times by not going for a cure.

When I tell my wife, Jeanne, who has a degree in Traditional Oriental Medicine and practices an ancient form of acupressure, her reaction is professional and predictable, but hardly comforting. “You’ve got to stop eating pork. And start eating tomatoes; you’re getting no lycopene. Diet, diet diet.”

And then it occurs to me: There may be an obvious explanation for the PSA spike. I’ve had the flu for two weeks. Some fever along with the usual symptoms. Was that enough to spike my PSA? It happened once before when we were living in Hawaii. Or is this my body telling me it is finally time to do something?

I remember something Mark wrote in “Snatchers” that is somewhat reassuring:“How the cancer behaves over time is the most important predictor. It supersedes Gleason score, it supersedes stage and PSA. . . In your case, Ralph, we’ve had two decades to observe its behavior, and that behavior has to trump all the stats.

In Mark’s experience, cancers do not tend to change their stripes after twenty years. “It’s like having new neighbors,” he once said. “With time you learn that they keep their property neat, that their dog won’t poop on your lawn, and that if you want to borrow a cup of sugar, sugar is what you’ll get. Well, the same with prostate cancer.”

Well, maybe prostate cancer has been my closest neighbor for long enough. I am once again in uncharted waters, and ultimately, there is risk in whatever I do. If I do nothing, I risk the cancer progressing. If I chose treatment, I risk unpleasant (or worse) side effects.

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MARK SCHOLZ, MD

Mark Scholz, MD is board certified in medical oncology and internal medicine. He has been treating men with prostate cancer exclusively since 1995. He is the Medical Director of Prostate Oncology Specialists, Inc., and Executive Director of the Prostate Cancer Research Institute. He is an acknowledged expert on management and treatment for prostate cancer using hormone intervention, immunotherapy, chemotherapy and angiogenesis as well as vitamin, herbal and other forms of lifestyle counseling. His affiliations include St. John's Health Center, Marina del Rey Hospital and others. Dr. Scholz also served as an associate clinical professor in the department of Oncology at USC School of Medicine. Dr. Scholz volunteers for the Internet list “Patient to Physician,” found via Resources at www.pcri.org . You may also find current posts on twitter. www.twitter.com/markscholzmd

RALPH H. BLUM

Ralph H. Blum is a cultural anthropologist and author, graduated Phi Beta Kappa from Harvard University with a degree in Russian Studies. His reporting from the Soviet Union, the first of its kind for The New Yorker (1961—1965), included two three-part series on Russian cultural life. He has written for various magazines, among them Reader’s Digest, Cosmopolitan, and Vogue. Blum has published three novels and five nonfiction books. He has been living with prostate cancer, without radical intervention, for twenty years.

PROSTATE ONCOLOGY SPECIALISTS

Established in 1995, Prostate Oncology Specialists has earned national acclaim for its comprehensive approach to prostate cancer prevention and management. Under the direction of Medical Director Mark Scholz, M.D., Prostate Oncology Specialists employs a highly skilled team of physicians trained in oncology, radiology, hematology, and internal medicine who treat all stages of prostate cancer. Prostate Oncology Specialists are not wedded to any single therapy for prostate cancer, but rather advocate the exploration of treatment options that are customized and tailored to the unique needs of each individual patient. Treatments employed include active surveillance, testosterone deprivation, partial cryotherapy, seed implantation, intensity-modulated radiation, and surgery. Prostate Oncology Specialists’ ongoing mission is to uncover new medical breakthroughs in the treatment and management of prostate cancer.

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